How to become a Multinational Association of Supportive Care in Cancer-designated center of excellence in supportive care in cancer

Purpose of review Aim of this review is to encourage and involve more doctors to take care of supportive care in cancer patients and to become centers of excellence. Recent findings In 2019, MASCC initiated a certification program to recognize oncology centers that demonstrate best practices in supportive cancer care but literature on how to become MASCC-designated center of Excellence in Supportive Care in Cancer is scarce and will be bulleted. Summary Becoming centers of excellence means not only the recognition of the clinical and managerial requirements to provide good supportive care but also the creation of a network of centers to participate in multicenter scientific projects and thus improve knowledge in the field of supportive care in cancer patients.


INTRODUCTION
According to the Multinational Association of Supportive Care in Cancer (MASCC), Supportive care is the prevention and management of the adverse effects of cancer and its treatment.This includes management of physical and psychological symptoms and side effects across the continuum of the cancer journey from diagnosis through treatment to posttreatment care.Supportive care aims to improve quality of life during anticancer treatments, quality of rehabilitation, secondary cancer prevention, survivorship, and end-of-life care [1].
Milestones in supportive care in cancer: (1) Supportive care aims to maintain (or improve) quality of life, and to ensure that people with cancer can achieve maximum benefit from their anticancer treatment.(2) Supportive care is relevant throughout the continuum of the cancer experience from diagnosis through treatment to posttreatment care (and encompasses cancer survivorship, and palliative and end-of-life care).(3) Supportive care involves a coordinated, personcentric, holistic (whole-person) approach, which should be guided by the individual's preferences, and should include appropriate support of their family and friends.(4) Supportive care is a basic right for all people with cancer, irrespective of their personal circumstances, their type of cancer, their stage of cancer, or their anticancer treatment.It should be available in all cancer centers, and other medical facilities that routinely manage people with cancer.(5) Supportive care represents an integrated model of medicine in oncology that in respect to other integration models fills a phase of the disease, which is related to oncologic treatments, clinical trials to allow cancer therapy to reach the effective dose-intensity and dosing interval thus allowing a global well being of the patients.
Supportive care is based on a multidisciplinary and multispecialistic approach.

SUPPORTIVE CARE CENTERS
Supportive care centers represent an alternative reference to emergency room and hospitalization for patients who are in adjuvant or palliative cancer treatments and require supportive medical pharmacological therapies aimed to monitor and treat the related toxicity thus to ensure greater adherence to the treatment protocols in terms of dose-intensity and interval of administration [2][3][4].Who should be dedicated to supportive care?

DESIGNATED CENTERS OF EXCELLENCE IN SUPPORTIVE CARE IN CANCER
MASCC certification provides for the application of a physician or nurse directly involved in supportive care, regardless of specialization but who knows medical oncology, the adverse effects of therapies, their prevention, and their treatment.Although supportive care is closely linked to medical oncology and radio-oncology, it has no specific specialty.However, because of the type of disease, adverse effects, and comorbidities, the presence of at least a medical oncologist, an internist, and a geriatric is the basis for a much broader multidisciplinary collaboration.In fact, most of the toxicities are related to internal medicine and geriatrics and may require diagnostic tests and pharmacological intravenous therapies.

How to apply?
The first step to become a MASCC-designated Center of Excellence in Supportive Care in Cancer is downloading the application form from the MASCC website [1], complete it in its entirety and also write a narrative part that tells how supportive care was born in the structure to which the applicant belongs, what are the daily activities that take place from the infusion therapies, relational point of view with the patient and family.Moreover, MASCC wants to know the basis of multidisciplinary and multispecialty, the collaboration with palliative care specialists and how the center has evolved since its establishment, where is it located (in the Oncological, Radiotherapy Department, together with Palliative Care, etc.).Main aims and benefits to become a MASCC Center of Excellence in supportive care in cancer are summarized in Fig. 1.

MULTINATIONAL ASSOCIATION OF SUPPORTIVE CARE IN CANCER EVALUATION CRITERIA AND FORM
MASCC evaluation criteria are:  (1) general, (2) a supportive care focus in clinical activities, (3) logistics, (4) research, and educational initiatives, (5) adherence to international guidelines.
Each part, excluding general, has a score.The scoring system has been realized between 0 and 100 to better synthesize with a number the center engagement on supportive care in cancer patients (0-100 is the most intuitive scale).
The minimum score that allows the definition of MASCC-Designated Centers of Excellence in Supportive Care in Cancer is 60 Part 1: general General information on the center and the applicant.This information will be compared with the other parts of the form.Any type of incoherence will generate a query to the applicant.

Part 2: a focus on clinical activities
This is the core of the evaluation.This part of the score evaluates how the center organizes the clinical activities around the concept of supportive care, trying to catch the heterogeneous solutions through a descriptive detailed text and specific questions.MASCC wants to know: (1) which supportive care therapies are provided to patients receiving cancer treatment at the center and in which setting are the treatment provided.Detailed information is required about the settings for each supportive therapy.(2) how are out-patients with treatment-related toxicity managed?(3) who are the people involved in the core supportive care team?All the activities are now performed by five physicians (two oncologists, two internists, one geriatrician), four RNs, three healthcare workers, and four volunteers selected and supervised by the Italian League Against Cancer (LILT).
The second MASCC-designated Center of Excellence in Supportive Care in Cancer is inside Pisa Medical Oncology (a Department of the University Hospital) from 2012, with a new model of working based on the direct assistance to patients with a new ambulatory room inside the oncological day hospital dedicated to symptoms and toxicities evaluation and management [3,4,6,7].The activity is conducted by one dedicated oncologist and two nurses together with two postgraduate medical doctors per day.
Supportive Care Service works 6 days per week in the morning for planned and unplanned adult patients with solid tumors (types of cancer and age) who enter the oncology department because of complications from treatment and gives an emergency telephone service through a mobile line for clinical enquiries.In the department are available beds for out and inpatients in oncology, radiotherapy, and hematology wards.
The early recognition of clinical problems may consent to treat them in the same day of access and in the next days if necessary, avoiding Emergency Room access in the same hospital.Symptoms and toxicities are evaluated also with the use of PROs (Patient Reported Outcomes) that better describe the patient's health condition, significantly reduce admission to Emergency Room and to Hospital and improve QoL of the patients [8,9  & ].The administration of symptomatic therapy (e.g.intravenous fluid infusions, collecting of blood samples and radiographic examination, pain, and nutritional therapy) and other specialists' further evaluations are feasible and direct.All the clinical activity is based on scientific society guidelines (MASCC, ESMO, ASCO, AIOM).
Moreover, everyday chaplain and psychologist may be involved in the clinical assistance for patient's spiritual and psychological needs.The psychologist, when necessary, in case of urgent consultation, cooperates with psychiatric ward.At the same time, there are an active program of palliative care consultation to provide adequate assistance for patients with advanced and not more treatable disease (according to ESMO, palliative care guidelines).This kind of activity is performed in collaboration with healthcare professional involved in homecare services and together with general practitioners.
The majority of visited outpatients have metastatic disease and are receiving active anticancer treatment.The main reasons for requiring a visit are uncontrolled symptoms and toxicities (pain, fatigue, anorexia, fever, diarrhea, nausea/vomiting).Only a small part of them require admission in our inpatients ward or to their wards through ER.
Across the years until today, this activity does increase and maintain its number of assisted patients (more than 1000 per year).
Positive and direct effect because of the SCC is a reduction by 3,2% of the number of unplanned hospitalizations of on-treatment cancer patients and the consequent net reduction by 2,2% of the costs used for unplanned hospitalizations.Furthermore, a reduction of about 5% in the ER accesses [5 & ] was described.Another important clinical and economic effect, is the marked decrease in the costs associated with red blood cell transfusions (net reduction of one-third of the total expense) [6], deeply according to the results of a previous study by Ripamonti et al. [10].
From the beginning, Supportive Care Service, does organize weekly staff rounds to discuss clinical cases and periodical meetings with the department healthcare professionals to widespread supportive care knowledge.
It is also maintained an active participation in national collaborative research studies in the field of supportive care and, furthermore, writing of paper for peer reviewed journals and abstracts submitted to national or international meetings.
In 2019, a narrative review by Northfield et al. [11] enhances both rationale and results of our models of care considering them essential for better patient's outcomes.
The opportunity to create these services in different oncological contests may be an interesting opportunity for all healthcare providers.Until December 2022, MASCC have designated 20 Center of Excellence in Supportive Care in Cancer worldwide, mostly in Europe.The excellence in supportive care has been documented in different type of structures, involving the cure of pediatric, adult, or geriatric cancer patients.Denomination and location of these centers are summarized in Table 1 and Fig. 1.
Again, the further way to increase the quality of these services through the MASCC certification as a center of excellence, is another effort to have better cancer care.

CONCLUSION
MASCC certification as a Center of Excellence in Supportive Care in Cancer includes the following benefits: (1) Use of the MASCC logo on marketing and advertising related to the center or program.(2) Use of the title 'A MASCC-Designated Center of Excellence in Supportive Care in Cancer'.
Applications are accepted on a rolling basis.Certification is valid for 3 years, after which the center must apply for re-evaluation.Centers with which members of the Certification Program Committee are affiliated may apply.However, the relevant committee members must recuse themselves from the evaluation process.Candidates are encouraged to become MASCC members and promote the membership in their institution.

( 1 )
Centrality of patientKEY POINTSSupportive Care as an integrated model of medicine in oncology.Supportive Care Centers: different organizational models according to MASCC mission.MASCC-Designated Center of Excellence in Supportive Care in Cancer.

FIGURE 1 .
FIGURE 1.The stars in the picture represent geographic areas of the 20 centers, mostly in Europe, actually certificated as MASCC-designated Center of Excellence in Supportive Care in Cancer.

Table 1 .
MASCC-designated Center of Excellence in Supportive Care in Cancer 2019-2022 Hospital of Eastern Ontario, Division of Hematology/Oncology Ottawa, Canada 20 McMaster Children's Hospital, Hamilton Health Sciences, Division of Hematology and Oncology Hamilton, Canada